Exhibit (5) Form of Application for the Allstate Variable Annuity 3
AssetManager
VA3 ASSETMANAGER
APPLICATION FOR FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY
ISSUED BY: ALLSTATE LIFE INSURANCE COMPANY OF NEW YORK
P.O. BOX 94038, Palatine, IL 60094-4038, Telephone: 1-800-256-9392
Overnight Address: 3100 Sanders Road., M4A, Northbrook, IL 60062
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OWNER(S)
Name______________________________ // M // F Birthdate __/__/__
Address___________________________ Soc. Sec. No. ____-___-____
City State Zip
Name______________________________ // M // F Birthdate __/__/__
Address___________________________ Soc. Sec. No. ____-___-____
City State Zip
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ANNUITANT
Leave blank if annuitant is the same as sole Owner; otherwise complete.
Name______________________________ // M // F Birthdate __/__/__
Address___________________________ Soc. Sec. No. ____-___-____
City State Zip
Relationship to Owner _____________________________________
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BENEFICIARY(IES)
Name _______________________________ Relationship to Owner ______________
Name _______________________________ Relationship to Owner ______________
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<TABLE>
<CAPTION>
PURCHASE PAYMENT/PLAN OPTIONS
Total Purchase Payment $__________________
PORTFOLIO SELECTION MSAM Funds
<S> <C>
AIM Variable Insurance Funds //Equity Growth ___%
//Aggressive Growth ___% //International Magnum ___%
//Blue Chip ___% //Emerging Markets Equity ___%
//Growth ___% //U.S. Real Estate ___%
//Value ___% //Mid-Cap Value ___%
Alliance Variable Produce Series Fund Putnam Variable Trust
//Growth ___% //Growth & Income ___%
//Growth & Income ___% //International Growth ___%
//Premier Growth ___% //International New Opportunities ___%
MSDW Variable Investment Series //New Opportunities ___%
//Money Market ___% //OTC & Emerging Growth ___%
//Quality Income Plus ___% //Voyager ___%
//High Yield ___% Van Kampen Life Investment Trust
//Utilities ___% //Emerging Growth ___%
//Income Builder ___% Fixed Account
//Dividend Growth ___% //DCA Fixed Account ___%
//Capital Growth ___% //_________________ ___%
//Global Div. Growth ___% //_________________ ___%
//European Growth ___% Total 100%
//Pacific Growth ___% Plan Options (if not selected, base policy will apply):
//Equity ___% //Performance Death Benefit Option
//S&P 500 Index ___% (Highest Anniversary Value)
//Competitive Edge ___%
//Strategist ___%
//Aggressive Equity ___%
//Short-Term Bond ___%
</TABLE>
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REPLACEMENT INFORMATION
Will this annuity replace or chane any exisitng annuity or life insurance?
// Yes //NO (If Yes, complete the following.)
Company _____________________________ Policy No. ___________________
Cost basis amount ___________________ Policy Date __________________
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TAX QUALIFIED PLAN
// Yes // No (If Yes, complete the following.)
o Traditional IRA o Roth IRA o SEP o Other ______
o 403(b) (TSA) o 401(a) (pension)
// Transfer //Rollover
// Contribution $______ Contribution Year ___________
(attach Form 5305 for SEP)
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SPECIAL INSTRUCTIONS
____________________________________________________________________________
____________________________________________________________________________
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SIGNATURE(S)
A copy of this application signed by the agent will be the receipt for the first
purchase payment. If Allstate Life Insurance Company of New York ("Allstate
Life of New York") declines this application, Allstate Life of New York will
have no liability except to return the first purchase payment.
I have read the above statements and represent that they are compete and true to
the best of my knowledge and belief. I agree that this application shall be a
part of the Contract issued by Allstate Life of New York. By accepting the
Contract issued, I agree to any additions or corrections to this application.
Allstate Life of New York will obtain written agreement from me for any change
in the investment allocation, benefits, type of plan, or birthdates.
I understand that contract values and income payments based on the investment
experience of a separate account are variable and not guaranteed as to dollar
amount. I acknowledge receipt of the current prospectus for the Flexible
Premium Deferred Variable Annuity.
Signed at ______________________________________ Date __/__/__
City State
Owner(s)______________________________________________________
Annuitant ____________________________________________________
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REPRESENTATIVE USE ONLY
Will the annuity applied for replace or change any existing annuty or life
insurance? // Yes // No
Rep Name (Please Print) _________________ Phone No. ( ) ___-____
Rep Signature ___________________________ Transaction No. _________________
